Effect of a Multifaceted Intervention on Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil The BRIDGE-ACS Randomized Trial
Effect of a Multifaceted Intervention on Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil The BRIDGE-ACS Randomized Trial
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DOI：
10.1001/jama.2012.413
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发表时间：
2012-05-16
影响因子：
120.7
通讯作者：
Lopes, Renato D.
中科院分区：
文献类型：
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作者：
Berwanger, Otavio;Guimaraes, Helio P.;Lopes, Renato D.
背景研究发现，急性冠脉综合征(ACS)患者通常不会在社区实践中接受循证治疗。在低收入和中等收入国家尤其如此。目的评估多方面的质量改进(QI)干预是否可以改善循证治疗的使用，并降低中等收入国家ACS患者的主要心血管事件的发生率。设计、设置和参与者BRE桥-ACS(巴西干预措施，以增加急性冠脉综合征的证据使用)试验，这是一项在巴西34个集群(公立医院)中进行的整群随机(隐蔽分配)试验，从2011年3月15日到2011年11月2日共纳入1150名ACS患者，随访至1月27日。2012年。干预多方面的QI干预，包括临床医生的教育材料、提醒、算法和病例经理培训，与常规做法(对照)相比。主要结果衡量主要终点是无禁忌症的患者在最初24小时内接受所有循证治疗(阿司匹林、氯吡格雷、抗凝剂和他汀类药物)的患者的百分比。结果纳入患者的平均年龄为62岁(SD，13岁)；男性占68.6%，ST段抬高心肌梗死占40%，非ST段抬高心肌梗死占35.6%，不稳定型心绞痛占23.6%。随机分组包括79.5%的教学医院，全部来自主要城市地区，41.2%的教学医院具有24小时经皮冠状动脉介入治疗能力。在符合条件的患者中(923/1150[80.3%])，干预组中67.9%的患者接受了所有符合条件的急性治疗(人群平均优势比[ORPA]，2.64[95%CI，1.28~5.45])，对照组为49.5%。同样，在符合条件的患者中(801/1150[69.7%])，干预组患者更有可能接受所有符合条件的急性和出院药物治疗(50.9%比31.9%；ORPA，2.49[95%CI，1.08-5.74])。总体综合依从性得分在干预组中更高(89%比81.4%；平均差异8.6%[95%可信区间2.2%-15.0%])。干预组住院心血管事件发生率为5.5%，对照组为7.0%(ORPA，0.72[95%CI，0.36-1.43])；30天全因死亡率为7.0%，8.4%(ORPA，0.79[95%CI，0.46-1.34])。结论在巴西接受治疗的ACS患者中，多方面的教育干预显著改善了循证治疗的使用。
Context Studies have found that patients with acute coronary syndromes (ACS) often do not receive evidence-based therapies in community practice. This is particularly true in low- and middle-income countries.Objective To evaluate whether a multifaceted quality improvement (QI) intervention can improve the use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country.Design, Setting, and Participants The BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized (concealed allocation) trial conducted among 34 clusters (public hospitals) in Brazil and enrolling a total of 1150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012.Intervention Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, vs routine practice (control).Main Outcome Measures Primary end point was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications.Results Mean age of the patients enrolled was 62 (SD, 13) years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non-ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1150 [80.3%]), 67.9% in the intervention vs 49.5% in the control group received all eligible acute therapies (population average odds ratio [ORPA], 2.64 [95% CI, 1.28-5.45]). Similarly, among eligible patients (801/1150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs 31.9%; ORPA,, 2.49 [95% CI, 1.08-5.74]). Overall composite adherence scores were higher in the intervention clusters (89% vs 81.4%; mean difference, 8.6% [95% CI, 2.2%-15.0%]). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group (ORPA, 0.72 [95% CI, 0.36-1.43]); 30-day all-cause mortality was 7.0% vs 8.4% (ORPA, 0.79 [95% CI, 0.46-1.34]).Conclusion Among patients with ACS treated in Brazil, a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies.